咳嗽与咳痰 （ 咳嗽与咳痰 （ Cough & Expectoration ) 原南京中大附属医院神内科主任、硕士生导师 佛山大学医学院医学系孟红旗教授、主任医师 Professor 、 Doctor director 、 Neurologist

cough Concept and Definition of cough Coughing is an essential defense mechanism that it prevents the airways from the foreign substance and clear the excretion of respiratory tract. Coughing is a reflex. permanent and frequent coughing indicates an abnormality.

Concept and definition of Expectoration Expectoration is a pathological phenomenon that human being remove the pathological secretion from respiratory system by means of coughing.

cough and cough and expectoration The daily quantity of bronchial secretions produced by a normal person is unknown. But it is sufficiently small to be removed by mucocillary action alone. Cough and expectoration are not required

概 念 咳嗽（ cough ）是一 种保护性反射动作， 呼吸道内的分泌物或 进入气道的异物可借 咳嗽反射排除体外。 咳痰 （ expectoration ） 是通过咳嗽动作将呼 吸道或肺部的分泌物 排出口腔外的动作。

Mechanism Mechanical, chemical, inflammation →larynx, trachea, bifurcation of the bronchi. →Afferent fibers are in the vague nerve →cough center. Efferent signals →larynx → muscles of diaphragm, chest wall, abdomen A coordinated series of movement complete the cough. Deep inspiration – expiration effort with glottis closed - glottis open abruptly – high velocity of airflow brings out secretions from airways.

发生机制 1 ．咳嗽 咳嗽： 呼吸道粘膜、肺泡与胸膜以及呼吸系统 以外的器官，刺激经迷走神经、舌咽神 经和三叉神经的感觉神经纤维传入 延 髓咳嗽中枢 喉下神经、膈神经与 脊神经分别传到咽肌、声门、膈与其他 呼吸肌 咳嗽，同时呼吸道内分泌物 与异物（痰液）随之被排出。

发生机制 咳痰 ： 正常呼吸道粘液腺分泌少量粘液， 以保持呼吸道粘膜湿润。 当炎症、感染等病理情况下，粘膜或肺 泡充血、水肿，毛细血管通透性 ，腺体 分泌物 ，漏出物、渗出物与粘液、组织 坏死物等混合形成痰液。痰量增多借咳 嗽动作排出口腔外时方觉咳痰。

Etiology Respiratory pleural disease cardiovascular disease central nerve system factor

Respiratory disease Stimulator --- extra and intrathoracic --- from nose,oropharynx --- bronchi --- cough reflex. such as: 1.inhalation of foreign material 2.inflammation of respiratory tract 3.bleeding of respiratory tract 4.tumor of respiratory tract

Pleural Disease Such as: pleurisy, thoracic effusion pleural biopsy or pleuracentisis

Cardiovascular Disease Mitral stenosis --- left heart failure --- pulmonary edema --- trausudate or exudate --- stimulates intra-thoracic-cough receptor - -- cough Embolism of pulmonary can cause pulmonary venous pressure elevate --- pulmonary edema ---transudate or exudate ---stimulates intra thoracic cough receptor - --cough

Central nerve system Inflammatory of CNS can cause coughing such as: encephalitis and meningitis

病因 病因 1. 呼吸道疾病：炎症，异物，刺激性气体吸入， 肿瘤，出血等 → 刺激咽喉或支气管粘膜 → 咳嗽 反射。 2. 胸膜疾病：胸膜病变（炎症刺激） → 咳嗽 3. 心脏疾病：心功能不全 → 肺淤血、肺水肿 → 肺 泡内或支气管内浆液或浆液血性渗出刺激 → 咳 嗽 4. 中枢性因素：冲动从大脑皮层发出 → 刺激延髓 咳嗽中枢 → 引起咳嗽

Manifestation Character of cough The duration and pattern of cough The tone quality of cough The character and volume of sputum

Character of cough Cough without sputum---unproductive or dry cough mainly in the patient of acute pharyngitis, early stage of bronchitis,pleurisy and TB. Cough with sputum is called productive. It is caused by pneumonia, chronic bronchitis, bronchiectasis, lung abscess and cavitious TB

临床表现及其意义 1. 咳嗽的性质： （ 1) 干性咳嗽：指咳嗽时无痰或痰量甚 少，可见于急性咽喉炎、支气管炎、早 期肺结核等。 （ 2 ）湿性咳嗽：指咳嗽时伴有痰液 （气管渗出物），可见于肺炎、慢性支 气管炎、肺结核等。

The duration and pattern of cough Cough initiated ( 开始 ) suddenly --- acute upper airway infection Chronic cough --- chronic bronchitis, bronchial asthma and TB Paroxysmal cough --- whooping cough, bronchi compressed by tumor and TB

The duration and pattern of cough Periodic cough --- chronic bronchitis bronchiectasis related to the change of body position. Nocturnal cough---asthma, TB,chronic heart failure--associated with the vagal excitation at night.

临床表现及其意义 2. 咳嗽的时间与节律： （ 1 ）骤起咳嗽： ( 刺激性气体、异物或上呼吸道 急性炎症等） （ 2 ）慢性咳嗽：慢支炎、支扩等 （ 3 ）发作性咳嗽：（百日咳、肿瘤等） （ 4 ）夜间咳嗽：慢性心衰、肺结核等 （ 5 ）清晨或体位改变时咳嗽等：慢支炎、支扩、 肺脓肿等

The tone ( 音质 ) quality of cough It means the change of the sound and may suggest the the location of pathology. “ breaking ” cough --- epiglottal ( 会厌的 ) disease “ brassy ” cough --- tracheal airways “ hacking ” or “ cleaning of throat ” --postnasal discharge “ barking ” or “ croupy ” --laryngeal disease.

The tone quality of cough Hoarseness with cough --- larynto- tracheal bronchitis or impaired the function of recurrent laryngeal nerve,as from aneurysm of the aorta, left atrial enlargement,mediastinal malignancy. Inspiratory stridor --- upper airway obstruction

The tone quality of cough Cough with hemoptysis also raises the possibility of a malignant process, bronchiectasis, lung abscess, chronic bronchitis.

临床表现及其意义 3. 咳嗽的音色：指咳嗽时声音的色彩和特性 （ 1 ）咳嗽声音嘶哑：声带炎症或肿瘤等 （ 2 ）犬吠样咳嗽：会厌、喉部病变或气管受 压等 （ 3 ）金属音调样咳嗽：纵隔肿瘤、主动脉瘤、 肺癌等 （ 4 ）咳嗽声音微弱：极度衰竭或声带麻痹等

The character and volume of sputum Characters: mucoid, tenasious, purulent, blood stained.

Sputum: color White mucoid or serofluid sputum Yellow general bacterial infection Green aeruginosus Bacillus infection Grey or black dust inhalation Rusty Lobar pneumonia Pink cardiac edema Red hemoptysis

Sputum: foul odor anaerobic bacterium infection

Sputum: amount Bulk frothy ( 泡沫 ) sputum Pulmo edema Bulk serofluid sputum Alveolar carcinoma Bulk pus sputum Bronchiectasis Lung abscess Layering upper: frothy, middle: mucoid or mucopus, lower: necrosis substance

Sputum: consistency Mucoid sputum Bronchitis (without bacterial infection) Asthma Early stage of pneumonia Serofluid sputum Pulmo edema Pus sputum Any bacterial infection Bloody sputum

临床表现及其意义 4 ．痰的性状和量 性质：粘液性、浆液性、脓性、粘液脓性、血性等 成分：白色、铁锈色、黄色、粉红色、浅绿色等。 一般急性呼吸道炎症的痰为浆液或粘液性白痰； 肺淤血、肺水肿时，常咳粉红色泡沫样痰； 痰量少者仅有数毫升，见于呼吸道炎症； 静止后可分为三层：上层为 泡沫，中层为浆液或浆液脓性，底层为脓块及坏死组 织， 痰量多时可达数百毫升，静止后可分为三层：上层为 泡沫，中层为浆液或浆液脓性，底层为脓块及坏死组 织，见于支气管扩张或肺脓肿。脓痰有恶臭气味者提 示有厌氧菌感染。

The associated clinical features 1 、 cough with fever --- acute respiratory infection including measles, pneumonia, influenza, lung abscess, TB, pleurisy. 2 、 cough with chest pain --- plural cavity involve, heart disease, pneumonia, pleurisy, bronchogenic carcinoma.

The associated clinical features 3 、 cough with dyspnea edema of larynx, larynx tumor, chronic obstructive pulmonary disease, sever pneumonia, TB, massive pleural effusion, pulmonary congestion, pneumothorax and pulmonary edema. 4 、 cough with quantitative purulent sputum ---bronchiectasis, lung abscess, bronchi-fistula.

The associated clinical features 5 、 Cough with hemoptysis --- bronchiectasis, TB, lung tumor, lung abscess, mitral stenosis. 6 、 cough with clubbed fingers --- bronchiectasis, TB, lung abscess,carcinoma of lung, thoracic empyema （积脓）.

The associated clinical features Cough with wheeze --- bronchial asthma, cardiac asthma, foreign body in trachea and bronchi.

临床表现及其意义 5. 咳嗽、咳痰时伴随症状或体征 （ 1 ）咳嗽咳痰伴发热（感染性呼吸道炎症等） （ 2 ）咳嗽伴胸痛（感染性炎症、肿瘤、气胸等） （ 3 ）咳嗽咳痰伴体重减轻（结核、肿瘤等） （ 4 ）咳嗽伴咯血（结核、肿瘤、炎症等） （ 5 ）咳嗽伴呼吸困难（心肺疾患、气胸、胸腔积液 等） （ 6 ）咳嗽伴哮鸣音（支哮、气道异物、心性哮喘等） （ 7 ）咳嗽咳痰伴杵状指（趾）：支扩、肺脓肿、肿 瘤等

Investigation General condition of the patient Time characters Voice characters Productive or not In relation with posture Accompany with chest pain; with dyspnea, or other complications

[ 问诊要点 ] [ 问诊要点 ] ①发病年龄，咳嗽时间长短和节律等 ①发病年龄，咳嗽时间长短和节律等 ②咳嗽程度、音色与影响因素等 ②咳嗽程度、音色与影响因素等 ③咳嗽是否伴有咳痰，痰的颜色、性 状、量，有何特殊气味，痰中是否带 血等 ③咳嗽是否伴有咳痰，痰的颜色、性 状、量，有何特殊气味，痰中是否带 血等